Reminder of important clinical lesson
CASE REPORT
Presurgical nasal moulding in a neonate with cleft lip Anshula Deshpande,1 Dixit Shah,2 Chirag S Macwan1 1
Department of Pedodontics and Preventive Dentistry, K M Shah Dental College, Sumandeep Vidyapeeth, Vadodara, Gujarat, India 2 Department of Oral and Maxillofacial Surgery, K M Shah Dental College and Hospital, Vadodara, Gujarat, India Correspondence to Professor Anshula Deshpande, [email protected]
SUMMARY The concept of presurgical nasoalveolar moulding (PNM) was developed to improve the aesthetic result of surgically corrected cleft lip. This paper presents the method of fabrication of PNM appliance and the case of a 30-day-old neonate with unilateral cleft lip in whom nasal moulding was performed. Treatment was initiated at 30 days and continued for 60 days after which the surgical correction of cleft lip was performed. Significant improvement in aesthetics and symmetry of the nose was achieved at the end of the treatment. Figure 1
Accepted 25 May 2014
Preoperative extraoral frontal view.
BACKGROUND Numerous techniques have been advocated by several authors to align cleft segments in the desired position. McNiel,1 Georgiade and Latham,2 Hotz et al3 have proposed methods for alveolar moulding in a cleft palate patient. All of these methods are aimed at correcting only the alveolar cleft, nasal deformity remains the greatest aesthetic challenge. To improve the aesthetic result of surgically corrected cleft lip, the concept of presurgical nasoalveolar moulding (PNM) was developed. Grayson et al,4 in 1993, advocated a technique to mould the alveolus, lip and nose in cleft lip and palate cases. Matsuo et al,5–7 in their series of research articles, described timing and outcome of the moulding of nasal cartilage. This article presents the case report of a neonate with cleft lip where nasal moulding was performed, the method of appliance fabrication and analysis of nasal outcome has been elaborated.
CASE PRESENTATION A 1-month-old child with a cleft lip was referred to our department. The medical history of the child, and parents was unremarkable. Extraoral and intraoral examination of the child revealed unilateral incomplete cleft lip on the left side (figures 1 and 2). Because the child was scheduled for surgery at 3 months, presurgical nasal moulding was planned. The treatment method was explained to the parents and informed consent was obtained.
To cite: Deshpande A, Shah D, Macwan CS. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201989
Mumbai, India) on the poured primary cast. A final mucostatic impression was made using a special tray with alginate impression material (Imprint, DPI, Mumbai, India) and poured with type-III dental stone (figure 3). Since the baby was crying during both the impression making procedures, it was ensured that she faced the floor to make sure that no impression material was ingested. The required amount of alginate material was loaded on the tray and once alginate was set the impression was relieved and removed in a single snap. Modelling wax was adapted over the final cast. A 5 mm×10 mm cylindrical-shaped wax was attached at a 40° angulation at the anterior aspect of the cast. A 19-gauge stainless steel wire was secured in the wax pattern to fabricate the nasal stent (figure 4). The final wax model was flasked, dewaxed and acrylised using pink heat cure acrylic (RR Heat Cure, DPI, Mumbai, India). Fabrication of nasal stent was performed as described by Grayson and Maull.8 Distance between nose and alveolus was measured using dental floss. Length of
TREATMENT A primary impression of the maxillary arch was made with polyvinyl siloxane putty (Aquasil Soft Putty, Dentsply Limited, UK). The impression was filled with plaster of Paris. A special tray was fabricated using self-cure acrylic (RR Cold Cure, DPI,
Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Figure 2
Preoperative extraoral basal view. 1
Reminder of important clinical lesson Figure 3 (A) Primary siloxane impression of upper arch; (B) primary cast of upper arch for fabrication of special tray; (C) special tray for final impression of upper arch and (D) final working cast.
stainless steel wire was decided accordingly. The R shape was given at the free end of the wire. Dough of cold cure acrylic was placed over the R-shaped stainless steel wire. Shape of the cold cured nasal stent follows the shape of the R-shaped armature (figure 5). After that, the appliance was finished and polished (figure 6).
Half inch diameter red small orthodontic elastic ( J J Orthodontics, Chalakudy, Kerala, India) was used for retention of the appliance. First, a half inch width micropore tape was applied to the non-cleft side, then pulled over and adhered to the cleft side to approximate the lip; the philtrum and columella should be brought to the midline. Second, a three-fourth inch width micropore tape was inserted in the elastic and folded on them for both the right and left side. Then elastics were engaged in the groove of the retentive button of the appliance. Before placement of the appliance into the oral cavity denture, relining material was used to shape the nasal stent and help in preventing traumatic ulceration to the nasal cavity and provide the desired moulding for the alar of the nose and enhance the columnar width. After that, the appliance was inserted in the oral cavity and micropore tapping was performed on the patient’s face (figure 7). This entire procedure was taught to the parents and possible complication was described to them. The patient’s parents were instructed to be careful while she is wearing the appliance. The appliance should be placed in cold water whenever the patient is not wearing the appliance. Proper cleanliness of the appliance should be maintained. The patient was placed on regular follow-up with 7–10 days interval for evaluation and adjustment of the nasal stent, if needed. Following completion of nasal moulding at 3 months of age, surgical correction of the cleft lip was performed (figure 8).
OUTCOME AND FOLLOW-UP Figure 4 Wax pattern for presurgical nasoalveolar moulding appliance fabrication. 2
During each follow-up visit thorough examination was performed to rule out any complication and on subsequent visits it was found that no complication occurred. The wire component Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Reminder of important clinical lesson
Figure 5 (A) R-shape bend at end of wire and (B) fabrication of nasal stent with cold cure acrylic. of the nasal stent was activated with the help of universal orthodontic plier so as to achieve blanching in the alar region of the nose which signifies that the required adjustment is achieved for nasal moulding. No adjustment was required for the palatal part of the appliance. After completion of nasal moulding and surgical correction of the cleft lip a significant improvement
Figure 6 Finished and polished presurgical nasoalveolar moulding appliance. Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Figure 7
Appliance in situ (A) frontal view and (B) basal view.
compared with the beginning of the treatment was observed. Williams et al9 described the method of comparing preoperative and postoperative comparison of nasal changes. In the present case we have calculated and compared the preoperative and postoperative nostril height and width and height of the alar groove. Preoperative nostril height and width ratio of cleft and non-cleft side and height of alar groove ratio were calculated (figure 9). Postoperative nostril height and width ratio of cleft and non-cleft side and height of alar groove ratio were calculated (figure 10). Preoperative and postoperative values are given in table 1.
Figure 8
Postsurgical extraoral view. 3
Reminder of important clinical lesson Table 1 Comparison of preoperative and postoperative nostril height and width and height of the alar groove ratio Preoperative value Ratio of nostril height and width Ratio of alar groove height
Figure 9 Preoperative photographic measurement. (A) Nostril height and width ratio=the nostril height and width ratio on the cleft side (A0 /B0 )/the nostril height and width ratio on the non-cleft side (A/B) (where A=1.27 cm, B=1.48 cm, A0 =0.80 cm, B0 =2.54 cm. (B) The ratio of the height of the alar groove=the ratio of the height of the top of the alar groove on the cleft side (D0 /C0 )/the ratio of the height of the top of the alar groove on the non-cleft side (D/C) (where C=4.87 cm, D=2.78 cm, C0 =5.29 cm, D0 =3.15 cm). This result indicates that the nasal width was decreased, the columellar length was increased and the alar cartilage was moulded to a more normal shape compared with the beginning of treatment.
DISCUSSION The treatment of nasal moulding follows the principle that if the continuous low-grade pressure is applied it will result in reshaping and recontouring of the nasal cartilage. Alar cartilage
0.36 1.05
Postoperative value 0.67 1
is soft, plastic and malleable at birth, so it is mouldable during this period. Hardingham and Muir10 concluded that malleability of cartilage is because of the high oestrogen concentrations in the newborn’s blood during the first 15 days of life. Oestrogen eventually increases the level of hyaluronic acid, which is responsible for increased plasticity in the cartilage.10 To take the maximum advantage of this property of the cartilage, the nasal moulding should be planned within first 2 weeks of life. In the present case even though the patient reported at 4 weeks of age the treatment was planned so as to take advantage of the available retained elastic property of the nasal cartilage. Spengler et al11 studied the effect of nasoalveolar moulding and found that there was a significant increase in the bi-alar width and the columellar length and width after initiating treatment around 34 days, a similar study was conducted by Ezzat et al12 on the effect of PNM on unilateral cleft lip and palate patients which was initiated at 24 days and for an average 110 days. They concluded that the PNM therapy significantly increases the nasal symmetry by decreasing columellar deviation, increasing nostril height on the affected side, maintaining the bialar width of the nose, increasing columellar width and creating more symmetrical nostril heights and widths. Similarly, equivalent results were achieved in the present case with PNM suggestive of significant improvement in the nasal symmetry and aesthetics after the surgical correction.
Learning points ▸ Treatment of nasal and alveolar moulding should be started as early as possible, ideally within 15 days of life. ▸ Regular follow-up (once in 7–10 days) required during the presurgical nasoalveolar moulding (PNM) therapy as nasal stent may require minor adjustment. ▸ During surgical correction of cleft, surgeon felt ease in approximation and positioning of the muscle compared with children in whom PNM was not performed. ▸ PNM results in reduced number and cost of revision-surgical procedures for correction of nasal defects. ▸ After PNM therapy and surgical repair the lip healing is under minimal tension, thereby reducing scar formation.
Figure 10 Postoperative photographic measurement. (A) Nostril height and width ratio=the nostril height and width ratio on the cleft side (A0 /B0 )/the nostril height and width ratio on the non-cleft side (A/B) (where A=1.27 cm, B=2.12 cm, A0 =0.95 cm, B0 =2.33 cm. (B) The ratio of the height of the alar groove=the ratio of the height of the top of the alar groove on the cleft side (D0 /C0 )/the ratio of the height of the top of the alar groove on the non-cleft side (D/C) (where C=5.27 cm, D=3.31 cm, C0 =5.27 cm, D0 =3.31 cm). 4
Contributors All the authors have made an individual contribution to the writing of the article and not just been involved with the patient’s care. AD, DS and CSM were involved in the conception and design, acquisition of the data and interpretation. AD and CSM contributed by drafting the article and revising it critically for important intellectual content. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Reminder of important clinical lesson REFERENCES 1 2
3
4 5 6
McNiel C. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec 1950;70:126–32. Georgiade NG, Latham RA. Maxillary arch alignment in the bilateral cleft lip and palate infant, using pinned coaxial screw appliance. Plast Reconstr Surg 1975;56:52–60. Hotz M, Perko M, Gnoinski W. Early orthopaedic stabilization of the premaxilla in complete bilateral cleft lip and palate in combination with the Celesnik lip repair. Scand J Plast Reconstr Surg Hand Surg 1987;21:45–51. Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft-lip and palate. Plast Reconstr Surg 1993;92:1422–3. Matsuo K, Hirose T. Nonsurgical correction of cleft lip nasal deformity in the early neonate. Ann Acad Med Singapore 1988;17:358–65. Matsuo K, Hirose T, Otagiri T, et al. Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal period. Plast Reconstr Surg 1989;83:25–31.
7 8 9
10 11
12
Matsuo K, Hirose T. Preoperative non-surgical over-correction of cleft lip nasal deformity. Br J Plast Surg 1991;44:5–11. Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Clin Plast Surg 2004;31:149–8, vii. Williams EM, Evans CA, Reisberg DJ, et al. Nasal outcomes of presurgical nasal molding in complete unilateral cleft lip and palate. Int J Dent 2012;2012:643896. Hardingham TE, Muir H. The specific interaction of hyalurinic acid with cartilage proteoglicans. Biochim Biophys Acta 1972;279:401–5. Spengler AL, Chavarria C, Teichgraeber JF, et al. Presurgical nasoalveolar molding therapy for the treatment of bilateral cleft lip and palate: a preliminary study. Cleft Palate Craniofac J 2006;43:321–8. Ezzat CF, Chavarria C, Teichgraeber JF, et al. Presurgical nasoalveolar molding therapy for the treatment of unilateral cleft lip and palate: a preliminary study. Cleft Palate Craniofac J 2007;44:8–12.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
5
CASE REPORT
Presurgical nasal moulding in a neonate with cleft lip Anshula Deshpande,1 Dixit Shah,2 Chirag S Macwan1 1
Department of Pedodontics and Preventive Dentistry, K M Shah Dental College, Sumandeep Vidyapeeth, Vadodara, Gujarat, India 2 Department of Oral and Maxillofacial Surgery, K M Shah Dental College and Hospital, Vadodara, Gujarat, India Correspondence to Professor Anshula Deshpande, [email protected]
SUMMARY The concept of presurgical nasoalveolar moulding (PNM) was developed to improve the aesthetic result of surgically corrected cleft lip. This paper presents the method of fabrication of PNM appliance and the case of a 30-day-old neonate with unilateral cleft lip in whom nasal moulding was performed. Treatment was initiated at 30 days and continued for 60 days after which the surgical correction of cleft lip was performed. Significant improvement in aesthetics and symmetry of the nose was achieved at the end of the treatment. Figure 1
Accepted 25 May 2014
Preoperative extraoral frontal view.
BACKGROUND Numerous techniques have been advocated by several authors to align cleft segments in the desired position. McNiel,1 Georgiade and Latham,2 Hotz et al3 have proposed methods for alveolar moulding in a cleft palate patient. All of these methods are aimed at correcting only the alveolar cleft, nasal deformity remains the greatest aesthetic challenge. To improve the aesthetic result of surgically corrected cleft lip, the concept of presurgical nasoalveolar moulding (PNM) was developed. Grayson et al,4 in 1993, advocated a technique to mould the alveolus, lip and nose in cleft lip and palate cases. Matsuo et al,5–7 in their series of research articles, described timing and outcome of the moulding of nasal cartilage. This article presents the case report of a neonate with cleft lip where nasal moulding was performed, the method of appliance fabrication and analysis of nasal outcome has been elaborated.
CASE PRESENTATION A 1-month-old child with a cleft lip was referred to our department. The medical history of the child, and parents was unremarkable. Extraoral and intraoral examination of the child revealed unilateral incomplete cleft lip on the left side (figures 1 and 2). Because the child was scheduled for surgery at 3 months, presurgical nasal moulding was planned. The treatment method was explained to the parents and informed consent was obtained.
To cite: Deshpande A, Shah D, Macwan CS. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201989
Mumbai, India) on the poured primary cast. A final mucostatic impression was made using a special tray with alginate impression material (Imprint, DPI, Mumbai, India) and poured with type-III dental stone (figure 3). Since the baby was crying during both the impression making procedures, it was ensured that she faced the floor to make sure that no impression material was ingested. The required amount of alginate material was loaded on the tray and once alginate was set the impression was relieved and removed in a single snap. Modelling wax was adapted over the final cast. A 5 mm×10 mm cylindrical-shaped wax was attached at a 40° angulation at the anterior aspect of the cast. A 19-gauge stainless steel wire was secured in the wax pattern to fabricate the nasal stent (figure 4). The final wax model was flasked, dewaxed and acrylised using pink heat cure acrylic (RR Heat Cure, DPI, Mumbai, India). Fabrication of nasal stent was performed as described by Grayson and Maull.8 Distance between nose and alveolus was measured using dental floss. Length of
TREATMENT A primary impression of the maxillary arch was made with polyvinyl siloxane putty (Aquasil Soft Putty, Dentsply Limited, UK). The impression was filled with plaster of Paris. A special tray was fabricated using self-cure acrylic (RR Cold Cure, DPI,
Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Figure 2
Preoperative extraoral basal view. 1
Reminder of important clinical lesson Figure 3 (A) Primary siloxane impression of upper arch; (B) primary cast of upper arch for fabrication of special tray; (C) special tray for final impression of upper arch and (D) final working cast.
stainless steel wire was decided accordingly. The R shape was given at the free end of the wire. Dough of cold cure acrylic was placed over the R-shaped stainless steel wire. Shape of the cold cured nasal stent follows the shape of the R-shaped armature (figure 5). After that, the appliance was finished and polished (figure 6).
Half inch diameter red small orthodontic elastic ( J J Orthodontics, Chalakudy, Kerala, India) was used for retention of the appliance. First, a half inch width micropore tape was applied to the non-cleft side, then pulled over and adhered to the cleft side to approximate the lip; the philtrum and columella should be brought to the midline. Second, a three-fourth inch width micropore tape was inserted in the elastic and folded on them for both the right and left side. Then elastics were engaged in the groove of the retentive button of the appliance. Before placement of the appliance into the oral cavity denture, relining material was used to shape the nasal stent and help in preventing traumatic ulceration to the nasal cavity and provide the desired moulding for the alar of the nose and enhance the columnar width. After that, the appliance was inserted in the oral cavity and micropore tapping was performed on the patient’s face (figure 7). This entire procedure was taught to the parents and possible complication was described to them. The patient’s parents were instructed to be careful while she is wearing the appliance. The appliance should be placed in cold water whenever the patient is not wearing the appliance. Proper cleanliness of the appliance should be maintained. The patient was placed on regular follow-up with 7–10 days interval for evaluation and adjustment of the nasal stent, if needed. Following completion of nasal moulding at 3 months of age, surgical correction of the cleft lip was performed (figure 8).
OUTCOME AND FOLLOW-UP Figure 4 Wax pattern for presurgical nasoalveolar moulding appliance fabrication. 2
During each follow-up visit thorough examination was performed to rule out any complication and on subsequent visits it was found that no complication occurred. The wire component Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Reminder of important clinical lesson
Figure 5 (A) R-shape bend at end of wire and (B) fabrication of nasal stent with cold cure acrylic. of the nasal stent was activated with the help of universal orthodontic plier so as to achieve blanching in the alar region of the nose which signifies that the required adjustment is achieved for nasal moulding. No adjustment was required for the palatal part of the appliance. After completion of nasal moulding and surgical correction of the cleft lip a significant improvement
Figure 6 Finished and polished presurgical nasoalveolar moulding appliance. Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Figure 7
Appliance in situ (A) frontal view and (B) basal view.
compared with the beginning of the treatment was observed. Williams et al9 described the method of comparing preoperative and postoperative comparison of nasal changes. In the present case we have calculated and compared the preoperative and postoperative nostril height and width and height of the alar groove. Preoperative nostril height and width ratio of cleft and non-cleft side and height of alar groove ratio were calculated (figure 9). Postoperative nostril height and width ratio of cleft and non-cleft side and height of alar groove ratio were calculated (figure 10). Preoperative and postoperative values are given in table 1.
Figure 8
Postsurgical extraoral view. 3
Reminder of important clinical lesson Table 1 Comparison of preoperative and postoperative nostril height and width and height of the alar groove ratio Preoperative value Ratio of nostril height and width Ratio of alar groove height
Figure 9 Preoperative photographic measurement. (A) Nostril height and width ratio=the nostril height and width ratio on the cleft side (A0 /B0 )/the nostril height and width ratio on the non-cleft side (A/B) (where A=1.27 cm, B=1.48 cm, A0 =0.80 cm, B0 =2.54 cm. (B) The ratio of the height of the alar groove=the ratio of the height of the top of the alar groove on the cleft side (D0 /C0 )/the ratio of the height of the top of the alar groove on the non-cleft side (D/C) (where C=4.87 cm, D=2.78 cm, C0 =5.29 cm, D0 =3.15 cm). This result indicates that the nasal width was decreased, the columellar length was increased and the alar cartilage was moulded to a more normal shape compared with the beginning of treatment.
DISCUSSION The treatment of nasal moulding follows the principle that if the continuous low-grade pressure is applied it will result in reshaping and recontouring of the nasal cartilage. Alar cartilage
0.36 1.05
Postoperative value 0.67 1
is soft, plastic and malleable at birth, so it is mouldable during this period. Hardingham and Muir10 concluded that malleability of cartilage is because of the high oestrogen concentrations in the newborn’s blood during the first 15 days of life. Oestrogen eventually increases the level of hyaluronic acid, which is responsible for increased plasticity in the cartilage.10 To take the maximum advantage of this property of the cartilage, the nasal moulding should be planned within first 2 weeks of life. In the present case even though the patient reported at 4 weeks of age the treatment was planned so as to take advantage of the available retained elastic property of the nasal cartilage. Spengler et al11 studied the effect of nasoalveolar moulding and found that there was a significant increase in the bi-alar width and the columellar length and width after initiating treatment around 34 days, a similar study was conducted by Ezzat et al12 on the effect of PNM on unilateral cleft lip and palate patients which was initiated at 24 days and for an average 110 days. They concluded that the PNM therapy significantly increases the nasal symmetry by decreasing columellar deviation, increasing nostril height on the affected side, maintaining the bialar width of the nose, increasing columellar width and creating more symmetrical nostril heights and widths. Similarly, equivalent results were achieved in the present case with PNM suggestive of significant improvement in the nasal symmetry and aesthetics after the surgical correction.
Learning points ▸ Treatment of nasal and alveolar moulding should be started as early as possible, ideally within 15 days of life. ▸ Regular follow-up (once in 7–10 days) required during the presurgical nasoalveolar moulding (PNM) therapy as nasal stent may require minor adjustment. ▸ During surgical correction of cleft, surgeon felt ease in approximation and positioning of the muscle compared with children in whom PNM was not performed. ▸ PNM results in reduced number and cost of revision-surgical procedures for correction of nasal defects. ▸ After PNM therapy and surgical repair the lip healing is under minimal tension, thereby reducing scar formation.
Figure 10 Postoperative photographic measurement. (A) Nostril height and width ratio=the nostril height and width ratio on the cleft side (A0 /B0 )/the nostril height and width ratio on the non-cleft side (A/B) (where A=1.27 cm, B=2.12 cm, A0 =0.95 cm, B0 =2.33 cm. (B) The ratio of the height of the alar groove=the ratio of the height of the top of the alar groove on the cleft side (D0 /C0 )/the ratio of the height of the top of the alar groove on the non-cleft side (D/C) (where C=5.27 cm, D=3.31 cm, C0 =5.27 cm, D0 =3.31 cm). 4
Contributors All the authors have made an individual contribution to the writing of the article and not just been involved with the patient’s care. AD, DS and CSM were involved in the conception and design, acquisition of the data and interpretation. AD and CSM contributed by drafting the article and revising it critically for important intellectual content. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
Reminder of important clinical lesson REFERENCES 1 2
3
4 5 6
McNiel C. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec 1950;70:126–32. Georgiade NG, Latham RA. Maxillary arch alignment in the bilateral cleft lip and palate infant, using pinned coaxial screw appliance. Plast Reconstr Surg 1975;56:52–60. Hotz M, Perko M, Gnoinski W. Early orthopaedic stabilization of the premaxilla in complete bilateral cleft lip and palate in combination with the Celesnik lip repair. Scand J Plast Reconstr Surg Hand Surg 1987;21:45–51. Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft-lip and palate. Plast Reconstr Surg 1993;92:1422–3. Matsuo K, Hirose T. Nonsurgical correction of cleft lip nasal deformity in the early neonate. Ann Acad Med Singapore 1988;17:358–65. Matsuo K, Hirose T, Otagiri T, et al. Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal period. Plast Reconstr Surg 1989;83:25–31.
7 8 9
10 11
12
Matsuo K, Hirose T. Preoperative non-surgical over-correction of cleft lip nasal deformity. Br J Plast Surg 1991;44:5–11. Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Clin Plast Surg 2004;31:149–8, vii. Williams EM, Evans CA, Reisberg DJ, et al. Nasal outcomes of presurgical nasal molding in complete unilateral cleft lip and palate. Int J Dent 2012;2012:643896. Hardingham TE, Muir H. The specific interaction of hyalurinic acid with cartilage proteoglicans. Biochim Biophys Acta 1972;279:401–5. Spengler AL, Chavarria C, Teichgraeber JF, et al. Presurgical nasoalveolar molding therapy for the treatment of bilateral cleft lip and palate: a preliminary study. Cleft Palate Craniofac J 2006;43:321–8. Ezzat CF, Chavarria C, Teichgraeber JF, et al. Presurgical nasoalveolar molding therapy for the treatment of unilateral cleft lip and palate: a preliminary study. Cleft Palate Craniofac J 2007;44:8–12.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Deshpande A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201989
5
